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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----- ------ ------------=------ , ----------- -� --� /a (Complete in Triplicate) Permit No., ---------=----------------------------------------------- c� f Date Issued --- ----------- -----------------------------------------_---,-.---_-.---____-------------------"-------_-"--- ,j This Permit Expires 1 Year From Date tissued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .."._ _- : --- ` Q ,`. Il, ------ -----------CENSUS TRACT • Owner's Name _ -` .��f"/ Nl Phone _ - -1't7" � l_�--X-------------- Address - --- ---� Ca-.._�.�--.�.D " pi/�,�'----/�-I��-�'----------------------•--• City -----/V-- ----- -- ----------------------------------- ........... Contractor's Name ------ -ID-41V--------------------------------------------------------License Phone :-- � � Installation will serve: -Residence [�_<partment House[] Commercial :❑Trailer Court ,❑ ` Motel ❑ Other -------------------------------------------- Number of living units:_-1-------- Number of bedrooms-------Garbage Grinder -_ Lot Size - -------------- Water Supply: Public System and name ------------------------------------------------------------- ------------------ ------Private Kr--- Character of soil to a depth of 3 feet. Sand' ilt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ,o Fill Material -------- --- If yes,type -_---__-------_----.------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) ` NEW INSTALLATION: (No septic tank or seepa i pit permitted if public��er is available within 200 feet,)�/ ri rn r PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size-�--X-��._X ---------- Liquid Depth _��--------------- Capacity)-2GAU-------- Type =-_b --- MaterialC<416J T- No. Compartments ................ O ` © ` Distance `to neatest: Well _��------------------------Foundati fn l-_---._-- Prop. Line----..:........ LEACHING LINE No, of Lines [� �----------------- Length of each line-,/4949---------------- Total Length ��f�--.---.---_--- 'D' Box f ".--. Type Filter Materiol4V C6-----.Depth Filter Material A?-oi........... ..............:.... ts ,,` Distance to nearest: Well -�-------------- Foundation /a----------------- Property Line.---•-------------- SEEPAGE PIT Depth ---------------- Diameter ---------------- Number ------------------------ --- Rock Filled Yes '❑ ido i❑ k Water Table Depth -----------------------------------------------Rock Size -------------------------------- Distance to nearest: Wel! ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date --------------------.-------------I SepticTank (Specify Requirements) --- ---- ------------------------------------------------------------------------------------:-----------------.------------------------•-••- DisposalField (Specify Requirements) ---------------------------------------------------------------------------------------------------------------------- ---------- -- ------.---- (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done--in accordance with San Joaquin County Ordinances, State Laws, and Rules and Reguiations•of the San Joaquin Local health District. Home owner or licen- sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." s Signed - ----------------- Owner BY fc Title .- �I /__2 - ---��_ a ---- ----- --------------------------- - - (If other than o n r) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ f -------------------------------------------------------------. DATE ------ -------------- BUILDINGPERMIT ISSUED ----------------------- ---I---------------------------------------------- - -----------------------------DATE ---------------------•- ------------ ------ ADDITIONAL--COMMENTS------- --- --------------------------------------------------------------- ------------ -------------------- -------------- -------------------------- ---- ----------------------------------------------------------------------- =-------------------------------- --------------------- -------------------------------- ------------ Final Inspection by: - - - - ------------------------------------- ---Date ----, �Z - ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M,